Anaesthesia for deep brain stimulation and in patients with implanted neurostimulator devices
2009; Elsevier BV; Volume: 103; Issue: 2 Linguagem: Inglês
10.1093/bja/aep179
ISSN1471-6771
Autores Tópico(s)Genetic Neurodegenerative Diseases
ResumoDeep brain stimulation has become an increasingly common treatment for Parkinson’s disease and other movement disorders. Consequently, it is important to understand the concepts of appropriate patient selection, the implantation process, and the various drugs and techniques that can be used to facilitate this treatment. Currently, none of the anaesthetic techniques for neurostimulator implantation has proven to be superior to others, although awake or sedation techniques are popular as they facilitate intraoperative neurological testing. However, even with meticulous anaesthetic care, perioperative complications such as hypertension and seizures do occasionally occur and close monitoring is required. Anaesthesia in patients with an implanted neurostimulator requires special considerations because of possible interference between neurostimulators and other devices. We have reviewed the current knowledge of anaesthetic techniques and perioperative complications of neurostimulator insertion. Anaesthetic considerations in patients with an implanted neurostimulator are also discussed. Deep brain stimulation has become an increasingly common treatment for Parkinson’s disease and other movement disorders. Consequently, it is important to understand the concepts of appropriate patient selection, the implantation process, and the various drugs and techniques that can be used to facilitate this treatment. Currently, none of the anaesthetic techniques for neurostimulator implantation has proven to be superior to others, although awake or sedation techniques are popular as they facilitate intraoperative neurological testing. However, even with meticulous anaesthetic care, perioperative complications such as hypertension and seizures do occasionally occur and close monitoring is required. Anaesthesia in patients with an implanted neurostimulator requires special considerations because of possible interference between neurostimulators and other devices. We have reviewed the current knowledge of anaesthetic techniques and perioperative complications of neurostimulator insertion. Anaesthetic considerations in patients with an implanted neurostimulator are also discussed. Functional stereotactic neurosurgery has become an increasing common treatment over the past 10 yr. In particular, deep brain stimulation (DBS)8Benabid AL Chabardes S Mitrofanis J Pollak P Deep brain stimulation of the subthalamic nucleus for the treatment of Parkinson’s disease.Lancet Neurol. 2009; 8: 67-81Abstract Full Text Full Text PDF PubMed Scopus (970) Google Scholar 48Limousin P Martinez-Torres I Deep brain stimulation for Parkinson’s disease.Neurotherapeutics. 2008; 5: 309-319Crossref PubMed Scopus (124) Google Scholar is now an effective treatment for Parkinson’s disease. Thalamic DBS was first developed for tremor control. Subsequently, subthalamic nucleus (STN) and internal globus palludus (GPi) stimulation were also investigated. In particular, STN stimulation can improve a wide range of parkinsonian symptoms and is currently the preferred target for most patients with this disease. The exact mechanism of action of this neurostimulation, however, remains unclear.37Johnson MD Miocinovic S McIntyre CC Vitek JL Mechanisms and targets of deep brain stimulation in movement disorders.Neurotherapeutics. 2008; 5: 294-308Crossref PubMed Scopus (219) Google Scholar Nonetheless, after this initial success in patients with Parkinson’s disease, the indications and applications for DBS have expanded to other disorders such as essential tremor, dystonia, chronic pain, and psychiatric disorders.51Lozano AM Hamani C The future of deep brain stimulation.J Clin Neurophysiol. 2004; 21: 68-69Crossref PubMed Scopus (32) Google Scholar 52Lozano AM Mahant N Deep brain stimulation surgery for Parkinson’s disease: mechanisms and consequences.Parkinsonism Relat Disord. 2004; 10: S49-S57Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar When STN DBS is contraindicated, thalamic DBS remains an option for patients with severe tremor, and GPi stimulation can be used for those with severe dyskinesia. The most common DBS hardware used (Medtronic, USA) has four main components: (i) the multicontact intracranial quadripolar electrodes, which are surgically inserted into the deep brain unilaterally or bilaterally, (ii) a plastic ring and cap seated onto a burr hole to fix the electrodes to the skull, (iii) a single- or dual-channel internal pulse generator (IPG), and (iv) an extension cable that is tunnelled s.c. from the cranial area to the chest or abdomen, connecting the DBS electrode(s) to the IPG. The battery lasts between 2 and 5 yr and has to be replaced together with the pulse generator. This article reviews the current knowledge regarding anaesthetic techniques for neurostimulator insertion. After a description of the surgical procedure, anaesthetic issues and possible perioperative complications will be discussed. Finally, anaesthesia for patients with a neurostimulator implant will be considered. The preoperative preparation starts with careful patient selection as this is a major determinant of successful postoperative outcome. As in any other procedure, the decision whether to operate on a patient is based on the risk-to-benefit assessment, balancing the risk of the procedure against the perceived improvement in quality of life. This is best accomplished using a multidisciplinary approach in which anaesthetic, medical, neurological, psychiatric, and social issues are assessed and addressed by a team consisting of anaesthetists, neurologists, neurosurgeons, neuropsychologists, and nurses. Surgery can be considered for Parkinson’s disease when the patient develops moderate to severe motor fluctuation, medication-induced dyskinesia, medication refractory tremor, or intolerance to medication. The most disabling symptoms should be identified and assessed as to whether they are dopa-sensitive or dopa-induced. Dopa-sensitive symptoms may be more likely to respond to surgery.94Welter ML Houeto JL Tezenas du Montcel S et al.Clinical predictive factors of subthalamic stimulation in Parkinson’s disease.Brain. 2002; 125: 575-583Crossref PubMed Scopus (338) Google Scholar The best timing for surgery is, however, still unclear. A multicentre study is in progress to evaluate the effect of STN DBS earlier in the course of disease.81Schupbach WM Maltete D Houeto JL et al.Neurosurgery at an earlier stage of Parkinson disease: a randomized, controlled trial.Neurology. 2007; 68: 267-271Crossref PubMed Scopus (214) Google Scholar Evaluation of suitability for surgery necessitates assessment of the patient’s general physical condition (in particular, cardiopulmonary co-morbidities), psychiatric history, and cognitive function.87Tarsy D Vitek JL Lozano AM Surgical Treatment of Parkinson’s Disease and Other Movement Disorders. Humana, Totowa, NJ2003Google Scholar The decision to operate on any particular patient should be individualized, taking into account the level of disability, risk factors for complications, general life expectancy, and patient motivation. Contraindications include factors that increase either the operative risk or risk of device malfunction and those that may limit the effectiveness of DBS (Table 1). Although there is no specific age limit for DBS, older patients may have only modest motor improvement94Welter ML Houeto JL Tezenas du Montcel S et al.Clinical predictive factors of subthalamic stimulation in Parkinson’s disease.Brain. 2002; 125: 575-583Crossref PubMed Scopus (338) Google Scholar and an increased incidence of cognitive dysfunction after STN stimulation. Dementia is a common problem in patients with Parkinson’s disease, posing practical obstacles to achieving optimal outcome. During DBS insertion, they may be unable to tolerate and cooperate during the awake procedures typically used and, after surgery, they may have trouble accurately observing and communicating their symptoms, complicating the adjustment of DBS and medication. Additionally, patients with pre-existing dementia may experience worsening of their cognitive status after surgery.79Saint-Cyr JA Trepanier LL Kumar R Lozano AM Lang AE Neuropsychological consequences of chronic bilateral stimulation of the subthalamic nucleus in Parkinson’s disease.Brain. 2000; 123: 2091-2108Crossref PubMed Scopus (522) Google Scholar A Mini Mental Status Exam (MMSE) score of <24 or a Mattis Dementia Rating Scale (MDRS) total score of <120 have been suggested as indicative of poor surgical candidacy.5Baltuch GH Stern MB Surgical Management of Movement Disorders. Taylor & Francis, Boca Raton2005Crossref Scopus (1) Google ScholarTable 1Contraindications to DBSPatients with increased operative risk or risk of device malfunction Patients with increased bleeding risk with brain penetration (e.g. coagulopathy, uncontrolled hypertension) Patients who will be exposed to MRI using a full body RF coil, a receive-only head coil, or a head transmit coil that extends over the chest area Patients who require the use of shortwave, microwave, or therapeutic ultrasound diathermy since diathermy energy can be transferred through the implanted system (or any of the separate implanted components)Patients with limited expected benefits from DBS Dementia and cognitive deficits Patients who are unable to properly operate the neurostimulator Patients with unsuccessful test stimulation Open table in a new tab Various medical conditions can substantially increase the surgical risk. The risk of intracranial haemorrhage is increased by poorly controlled hypertension, coagulopathy, magnetic resonance imaging (MRI) evidence of small vessel ischaemic disease, or extensive cerebral atrophy. Some clinicians require that a screening MRI of the brain be obtained before making a final decision on surgical candidacy. If an ‘awake’ technique is contemplated for the electrode insertion procedure, the patient’s ability to cooperate during the surgery should be evaluated. A history of claustrophobia or previous sedation failure warrants special attention. If MRI stereotactic planning will be carried out, it is imperative that a check is made for any previous ferromagnetic implant such as pacemaker, internal cardioverter-defibrillator (ICD), aneurysm clips, or cochlear implant. The feasibility of the planned surgical positioning should also be ascertained. Preoperative neurological status should be documented as there is a risk of deterioration after surgery. The medication regime needs to be carefully reviewed. Antiplatelet agents should be withheld if possible before and immediately after surgery. The need for chronic anticoagulation does not necessarily contraindicate surgery, but requires careful perioperative management of the coagulation status. As good hypertensive control is mandatory, antihypertensive medication should be continued. Patients and families should be given detailed verbal and written information about the procedure, the risks, and the potential benefits and also the limitations for any surgery. A clear description of what will happen and what patients will experience helps to clarify expectations. Questions must be fully addressed, and patients should be committed and motivated to work closely with the medical team. Patients are usually admitted the evening before surgery. A standard preoperative fasting regimen is implemented. Anti-parkinsonism medication is withheld to render the patients in an ‘off’ drug state for intraoperative neurological testing. Premedication should be used judiciously. Benzodiazepines and other GABA agonists can interfere with patients’ cooperation and tremor interpretation, and thus may be better avoided. Successful outcome with DBS relies on accurate insertion of electrodes. Target nuclei are localized using a combination of methods. Stereotactic MRI is useful as both STN and GPi are visible on MRI. Thalamic nuclei are not visible on standard MRI and thus require indirect targeting using atlas coordinates for pinpointing. On the day of surgery, a headframe is fitted on the patient’s head either under regional nerve blockade or local anaesthetic infiltration to the pin sites. A combined supraorbital and greater occipital nerve block may be better than local s.c. infiltration for this.92Watson R Leslie K Nerve blocks versus subcutaneous infiltration for stereotactic frame placement.Anesth Analg. 2001; 92: 424-427Crossref PubMed Scopus (34) Google Scholar The procedure is usually well tolerated without sedation or general anaesthesia except for uncooperative patients or those with severe dystonia. With the stereotactic frame in place, MRI is performed to identify target nuclei and allow surgical planning. In patients with a contraindication to MRI assessment, computer tomography has been used. After surgical planning is completed, the patient is brought to the operating theatre for electrode insertion, either unilaterally or bilaterally, as required. A burr hole procedure is performed, and a DBS electrode is passed down to the target area. To further fine tune the location of the electrode, a method known as microelectrode recording (MER) is frequently used. A microelectrode is passed along its trajectory towards the target nuclei (STN or GPi) as neuronal activities are simultaneously recorded. Specific brain structures can be identified based on their unique patterns of spontaneous neuronal firing. These neuronal discharges are viewed on an oscilloscope and played on an audio monitor since they are often best appreciated aurally. As the surgeon lowers the microelectrode in 50–100 µm increments, neurologists or neurophysiologists can make a scaled drawing of the cells encountered at each depth. This information then is superimposed on the brain atlas to assist in determining the electrode’s exact location. Finally, intraoperative macrostimulation through the inserted deep brain electrode allows observation and confirmation of clinical improvement and side-effects in a conscious patient. The anaesthetist’s aim in deep brain electrode insertion is to: (i) provide optimal surgical conditions and patient comfort, (ii) facilitate intraoperative monitoring, including neuromonitoring for target localization, and (iii) rapidly diagnose and treat any complications. As MER and macrostimulation have become important means of target localization, questions have arisen regarding the effect of anaesthetic agents on them. Anaesthetics can alter neuronal firing frequency78Ruskin DN Bergstrom DA Kaneoke Y Patel BN Twery MJ Walters JR Multisecond oscillations in firing rate in the basal ganglia: robust modulation by dopamine receptor activation and anesthesia.J Neurophysiol. 1999; 81: 2046-2055Crossref PubMed Scopus (115) Google Scholar and impair patient assessment. The use of gabaminergic sedative medication, even in small doses, has been shown to affect the quality of MERs.35Hutchison WD Lozano AM Microelectrode recordings in movement disorder surgery.in: Lozano AM Movement Disorder Surgery. Karger, Basel2000: 103-117Crossref Google Scholar Temporary modification and suppression of parkinsonian tremor has been reported with the use of propofol and remifentanil.11Bohmdorfer W Schwarzinger P Binder S Sporn P Temporary suppression of tremor by remifentanil in a patient with Parkinson’s disease during cataract extraction under local anesthesia.Anaesthesist. 2003; 52: 795-797Crossref PubMed Scopus (22) Google Scholar 12Burton DA Nicholson G Hall GM Anaesthesia in elderly patients with neurodegenerative disorders: special considerations.Drugs Aging. 2004; 21: 229-242Crossref PubMed Scopus (61) Google Scholar 45Krauss JK Akeyson EW Giam P Jankovic J Propofol-induced dyskinesias in Parkinson’s disease.Anesth Analg. 1996; 83: 420-422PubMed Google Scholar It is unclear which general anaesthetic agents allow the most effective MER. To date, only class IV data exit and there are no studies in the literature that have looked at their effects on MER data gathered specially in the context of DBS surgery for Parkinson’s disease. Consequently, an ‘awake’ technique has obvious advantages and most centres avoid anaesthesia at least during the mapping phase in order to best detect cellular activity and movement-related responses to neurostimulation. Options include monitored anaesthetic care with or without sedation, analgesia, or both.91Venkatraghavan L Manninen P Mak P Lukitto K Hodaie M Lozano A Anesthesia for functional neurosurgery: review of complications.J Neurosurg Anesthesiol. 2006; 18: 64-67Crossref PubMed Scopus (53) Google Scholar In the operating theatre, the patient with the headframe attached is carefully positioned in the semi-sitting position with special attention to patient comfort. I.V. access is established, and the degree of intraoperative monitoring is largely dictated by the patient’s co-morbidities. If the patient is conscious and cooperative, intraoperative electrical stimulation and assessment of clinical improvement is possible. Side-effects such as dysarthria, induction of dyskinesia, sensory deficits, eye movement, muscle cramps, and cerebellar signs can also be readily observed. In an ‘awake’ technique, the anaesthetist provides patient comfort and helps facilitate clinical testing. Withholding the anti-parkinson medications before surgery to optimize assessment can be unpleasant, with possible dystonia or even pain. During electrode placement, the patient’s head is usually fixed to the stereotactic apparatus, and the inability to move for a prolonged period of time after the procedure has commenced can be distressing. Furthermore, macrostimulation and performance of various tasks during neurophysiological testing is also exhausting. Good pain control, meticulous patient positioning and padding, attention to thermal control, and avoidance of excessive fluid administration to prevent bladder distension are thus very important. Patients should be encouraged to void before surgery and urinary catheterization is undesirable, particularly in males where a sheath catheter is a good alternative. Attention to detail, good patient communication, reassurance, and motivation are all necessary. Owing to the extreme sensitivity of subcortical areas of the brain to GABA receptor-mediated medications which may completely abolish MER and tremor, many physicians are reluctant to use sedative drugs, but many patients need sedation during the initial phase of surgery before neurophysiological testing. Ideally, the sedative effect should be readily reversible to allow patient cooperation. Benzodiazepines should be avoided. Propofol is popular and has been used extensively in neurosurgery, but its use in this setting is not straightforward. There is evidence that the pharmacokinetic behaviour of propofol in patients with Parkinson’s disease may differ from that of the population from which the target-controlled infusion models were developed.24Fabregas N Rapado J Gambus PL et al.Modeling of the sedative and airway obstruction effects of propofol in patients with Parkinson disease undergoing stereotactic surgery.Anesthesiology. 2002; 97: 1378-1386Crossref PubMed Scopus (33) Google Scholar Attempts to use the bispectral index to titrate the level of sedation in propofol anaesthesia during DBS also did not seem to offer any advantage regarding times to arousal, total propofol consumption, and cardiopulmonary stability.80Schulz U Keh D Barner C Kaisers U Boemke W Bispectral index monitoring does not improve anesthesia performance in patients with movement disorders undergoing deep brain stimulating electrode implantation.Anesth Analg. 2007; 104 (table of contents): 1481-1487Crossref PubMed Scopus (16) Google Scholar It is not yet clear whether propofol interferes with MER, but it is known to cause dyskinetic effects22Deogaonkar A Deogaonkar M Lee JY Ebrahim Z Schubert A Propofol-induced dyskinesias controlled with dexmedetomidine during deep brain stimulation surgery.Anesthesiology. 2006; 104: 1337-1339Crossref PubMed Scopus (23) Google Scholar 45Krauss JK Akeyson EW Giam P Jankovic J Propofol-induced dyskinesias in Parkinson’s disease.Anesth Analg. 1996; 83: 420-422PubMed Google Scholar and abolish tremor,2Anderson BJ Marks PV Futter ME Propofol-contrasting effects in movement disorders.Br J Neurosurg. 1994; 8: 387-388Crossref PubMed Scopus (38) Google Scholar which can hinder surgery and intraoperative testing. Another interesting, although unusual, problem is a tendency to occasionally cause sneezing. Although sneezing may seem harmless and readily resolves after propofol is stopped, it leads to patient discomfort, interferes with physiological mapping, and causes sudden increase in intracranial pressure (ICP) that could result in intracranial haemorrhage. An opioid (fentanyl or alfentanil), given minutes before propofol, eliminated the sneeze reflex in patients with periocular injections.86Tao J Nunery W Kresovsky S Lister L Mote T Efficacy of fentanyl or alfentanil in suppressing reflex sneezing after propofol sedation and periocular injection.Ophthal Plast Reconstr Surg. 2008; 24: 465-467Crossref PubMed Scopus (20) Google Scholar Dexmedetomidine reliably produces conscious sedation where the patient remains responsive and cooperative to verbal commands. This is mediated through activation of α2-adrenoreceptors in the locus coeruleus which is a major site of noradrenergic innervation in the central nervous system. It has been implicated as a key modulator for a variety of critical brain functions, including arousal, sleep, and anxiety.9Berridge CW Waterhouse BD The locus coeruleus-noradrenergic system: modulation of behavioral state and state-dependent cognitive processes.Brain Res Brain Res Rev. 2003; 42: 33-84Crossref PubMed Scopus (1776) Google Scholar This, together with minimal respiratory depression, makes it an attractive agent to use in ‘awake’ functional craniotomy. Low-dose infusion of this drug provides sedation from which patients are easily arousable and cooperative with verbal stimulation. Consequently, there are a number of reports on the successful use of the drug in this situation both alone1Almeida AN Tavares C Tibano A Sasaki S Murata KN Marino Jr, R Dexmedetomidine for awake craniotomy without laryngeal mask.Arq Neuropsiquiatr. 2005; 63: 748-750Crossref PubMed Google Scholar 7Bekker AY Kaufman B Samir H Doyle W The use of dexmedetomidine infusion for awake craniotomy.Anesth Analg. 2001; 92: 1251-1253Crossref PubMed Scopus (143) Google Scholar 53Mack PF Perrine K Kobylarz E Schwartz TH Lien CA Dexmedetomidine and neurocognitive testing in awake craniotomy.J Neurosurg Anesthesiol. 2004; 16: 20-25Crossref PubMed Scopus (126) Google Scholar and in combination with intermittent propofol.84Souter MJ Rozet I Ojemann JG et al.Dexmedetomidine sedation during awake craniotomy for seizure resection: effects on electrocorticography.J Neurosurg Anesthesiol. 2007; 19: 38-44Crossref PubMed Scopus (108) Google Scholar More importantly, since patient cooperation is maintained, this allows cognitive tests to be successfully carried out.75Rozet I Anesthesia for functional neurosurgery: the role of dexmedetomidine.Curr Opin Anaesthesiol. 2008; 21: 537-543Crossref PubMed Scopus (86) Google Scholar Dexmedetomidine has also been shown to attenuate the haemodynamic and neuroendocrine responses to headpin insertion in patients undergoing craniotomy and significantly reduce the concomitant use of antihypertensive medication.76Rozet I Muangman S Vavilala MS et al.Clinical experience with dexmedetomidine for implantation of deep brain stimulators in Parkinson’s disease.Anesth Analg. 2006; 103: 1224-1228Crossref PubMed Scopus (85) Google Scholar 90Uyar AS Yagmurdur H Fidan Y Topkaya C Basar H Dexmedetomidine attenuates the hemodynamic and neuroendocrinal responses to skull-pin head-holder application during craniotomy.J Neurosurg Anesthesiol. 2008; 20: 174-179Crossref PubMed Scopus (53) Google Scholar It can theoretically decrease cerebral blood flow via direct α2-mediated vascular smooth muscle constriction and, indirectly, via effects on the intrinsic neural pathways modulating vascular effects. α2-Agonists have a more potent vasoconstrictor effect on the venous than on the arteriolar side of the cerebral vasculature and can, therefore, decrease ICP. There is, so far, no evidence of adverse effects on cerebral haemodynamics associated with its use, even in the setting of a compromised cerebral circulation. Dexmedetomidine does not ameliorate clinical signs of Parkinson’s disease, such as tremor, rigidity, bradykinesia, or all. The pharmacologic profile of dexmedetomidine suggests that it may be an ideal sedative drug for deep brain stimulator (DBS) implantation.75Rozet I Anesthesia for functional neurosurgery: the role of dexmedetomidine.Curr Opin Anaesthesiol. 2008; 21: 537-543Crossref PubMed Scopus (86) Google Scholar Although dexmedetomidine has been successfully used in paediatric patients,3Ard J Doyle W Bekker A Awake craniotomy with dexmedetomidine in pediatric patients.J Neurosurg Anesthesiol. 2003; 15: 263-266Crossref PubMed Scopus (132) Google Scholar general anaesthesia may be necessary in some and also in adults who cannot tolerate the awake technique, either due to concurrent psychiatric problems, discomfort due to off-period dystonia, or severe anxiety with associated hypertension. The decision to use general anaesthesia is best made before surgery, as the presence of a stereotactic headframe can complicate airway management. It is unclear, if the lack of intraoperative assessment of motor disability and dyskinesia in patients who receive general anaesthesia actually results in a difference in surgical outcome. A retrospective study54Maltete D Navarro S Welter ML et al.Subthalamic stimulation in Parkinson disease: with or without anesthesia?.Arch Neurol. 2004; 61: 390-392Crossref PubMed Scopus (93) Google Scholar on the effect of general anaesthesia with i.v. propofol on the postoperative outcome of patients with Parkinson’s disease who underwent bilateral placement of electrodes within the STN concluded that both techniques were feasible. However, the residual motor disability and intensity of stimulation appeared to be slightly higher in patients under general anaesthesia, implying that STN stimulation was less precise in the absence of intraoperative clinical assessment. This result was not reproduced in another small study comparing awake stereotactic STN stimulation with general anaesthesia,95Yamada K Goto S Kuratsu J et al.Stereotactic surgery for subthalamic nucleus stimulation under general anesthesia: a retrospective evaluation of Japanese patients with Parkinson’s disease.Parkinsonism Relat Disord. 2007; 13: 101-107Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar which found no significant difference in the degree of postoperative improvement rate, postoperative S-E ADL scores, or the amplitude of STN stimulation. Both total i.v. anaesthesia and inhalation techniques have been used in patients unsuitable for a conscious technique. Once the electrodes are inserted, the burr holes can be closed off. In some centres, the insertion of electrodes is routinely followed by radiological confirmation. Implantation of the pulse generator and internalization of electrodes can be performed either immediately or as second-stage surgery under general anaesthesia. Postoperative monitoring is necessary even in patients recovering from sedation. Patients should receive their usual anti-parkinsonian medication as soon as possible to avoid motor fluctuation that could cause profound deterioration in neurological function and respiratory muscle impairment. There is limited information on the incidence of intraoperative anaesthetic complications. A review of intraoperative anaesthetic-related complications in small series of 158 cases of deep brain ablation or stimulation under sedation with propofol or dexmedetomidine41Khatib R Ebrahim Z Rezai A Anesthetic complications during deep brain stimulation.Anesthesiology. 2004; 101: A379Google Scholar found that intraoperative events occurred in 6.96% of cases. These events included coughing, sneezing, aspiration, pulmonary oedema, combative behaviour and agitation/confusion, bronchospasm, angina, and intracranial haemorrhage. In a subsequent paper,42Khatib R Ebrahim Z Rezai A et al.Perioperative events during deep brain stimulation: the experience at Cleveland clinic.J Neurosurg Anesthesiol. 2008; 20: 36-40Crossref PubMed Scopus (66) Google Scholar the same group reviewed 258 electrode insertion procedures under a variety of techniques, including monitored anaesthetic care and general anaesthesia (Table 2). The most common neurological complications were intracranial haemorrhage and seizure. Age ≥64 yr was found to be an independent risk factor for complications during DBS. In another report of 172 DBS and six ablative procedures, intraoperative adverse events occurred in 16%.91Venkatraghavan L Manninen P Mak P Lukitto K Hodaie M Lozano A Anesthesia for functional neurosurgery: review of complications.J Neurosurg Anesthesiol. 2006; 18: 64-67Crossref PubMed Scopus (53) Google Scholar The most frequent were seizure (4.5%) and hypertension (3.9%). Rarer complications included decreased level of consciousness (2.2%), neurological deficit (0.6%), airway obstruction (1.1%), respiratory distress (1.1%), excessive pain (1.1%), nausea and vomiting (1.7%), and blood loss (0.6%).Table 2Reported intraoperative complications of DBS insertion and their incidencesKhatib and colleagues42Khatib R Ebrahim Z Rezai A et al.Perioperative events during deep brain stimulation: the experience at Cleveland clinic.J Neurosurg Anesthesiol. 2008; 20: 36-40Crossref PubMed Scopus (66) Google ScholarVenkatraghavan and
Referência(s)